Aeromonas hydrophila Infection following Leech Therapy for the Treatment of Nipple-Areola Complex Congestion after Breast Reduction: A Case Report.

Several strategies for the management of venous congestion of the nipple-areola complex (NAC) after reduction mammaplasty have been proposed. Among these, hirudotherapy represents an ancient but still effective method, even though the risk of infections related to leeches should be considered. We report a peculiar case of breast infection and sepsis after leech therapy in a patient who underwent a reduction mammaplasty. A prompt surgical debridement of the wounds and necrotic tissues associated with targeted antibiotic therapy led to a fast improvement of clinical conditions, and partial preservation of the NAC was obtained. Accurate knowledge of the clinical presentation of soft tissue infections related to leeching allows for an early diagnosis and would serve as a warning for surgeons who approach such breast cosmetic procedures.

An unusual case of dermatofibrosarcoma protuberans misdiagnosed as vascular malformation for over 30 years: A case report.

INTRODUCTION: Dermatofibrosarcoma protuberans (DFSP) is a rare and slowly growing soft tissue tumor and it is frequently misdiagnosed and mismanaged like more common masses. Therefore diagnostic delays are common and may result in challenging reconstructions. CASE PRESENTATION: We report the peculiar case of a 36-year-old patient with dermatofibrosarcoma protuberans of the right iliac fossa misdiagnosed as vascular malformation for over 30 years. Due to the delayed diagnosis resulting in a large tumor to be resected, surgical reconstruction was performed with a miniabdominoplasty approach with an excellent cosmetic and functional result. DISCUSSION: The review of the literature showed that mismanagements and delayed diagnosis of this sarcoma are frequent. Large skin and soft-tissue defects are frequently encountered in the surgical treatment of this tumor, and adequate knowledge of the reconstructive options is mandatory to provide the best possible outcome. CONCLUSIONS: Superficial skin masses could be easily misdiagnosed. These diagnostic delays may lead to increased patient morbidity and more challenging reconstructive procedures. In this scenario, preoperative biopsies of suspicious lesions may be useful to avoid mismanagement of rare malignant neoplasms such as DFSP. In some challenging cases, the use of a surgical approach typical of cosmetic procedures may be useful to obtain satisfactory aesthetic and functional results.

The Oxygen Therapy Tube as a Tool for Breast Squeezing during Pedicle De-epithelialization in Reduction Mammaplasty.

During breast reduction, pedicle de-epithelialization, as meticulous as possible, is necessary to ensure satisfying breast sculpting and to avoid any epidermoid cyst. To perform an effective and rapid de-epithelialization, a good tension of the skin is mandatory. Several techniques to improve skin tension of the breast are described in the literature. We report a cheap, effective, and easily reproducible method, based on the use of an oxygen tube with nasal cannula.

The Impact of Reduction Mammaplasty on Breast Sensation: A Systematic Review.

Loss of sensation is one of the most feared complications of breast reduction surgery. Although several techniques have been proposed to maximize sensitivity preservation, the scientific literature still reports contradictory findings. This systematic review aimed to assess whether breast reduction mammaplasty is associated with measurable changes in breast sensation. This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed (National Institutes of Health, Bethesda, MD), Scopus (Elsevier, Amsterdam, the Netherlands), and Web of Science (Clarivate, Philadelphia, PA) databases were searched for clinical studies investigating breast sensation after breast reduction mammaplasty. The initial search identified 1523 studies of which 22 articles met our specific inclusion criteria. Most of the included studies are consistent in describing only transient sensation decrease or even sensation improvement after surgery compared to the presurgery condition with any approach, except those investigating outcomes after superior or superolateral pedicle reduction mammaplasty. Nevertheless, the overall quality of evidence is low or very low due to the limited availability of randomized controlled trials or controlled studies and the high risk of bias.

Nasal Retainer 2.0: A New, Cheap, and Reliable Method to Prepare Custom-made Nostril Retainer for Nasal Reconstruction.

Total nasal reconstruction always represents a challenge for the plastic surgeon, who must deal both with the reconstructive procedure and compliance of the patient. This kind of reconstruction often requires more than one step. Therefore, more prolonged and emphasized scarring than normal can occur, thus resulting in a higher risk of nostril stenosis. Although several nasal retainers have been described, traditional premade retainers could be poorly tolerated by patients and need to be adequately customized to improve patient compliance. Herein, the authors propose a new, cheap, and reliable method to prepare customized nasal retainers which can be used after every step of nasal reconstruction.

The Role of Surgical Drainage on Complications after Sentinel Lymph Node Biopsy for Melanoma.

The real benefit of using drains for reducing the risk of complications in sentinel lymph node biopsy (SLNB) has not been investigated yet. We aimed to evaluate the role of drain after SLNB and to determine if a correlation exists between drains and early complications. Methods: This is a retrospective study of patients who underwent SLNB for melanoma from 2016 to 2021. Patients were dichotomized into two groups according to the use of drain. The between-group comparison (drainage group versus no drainage group) was performed by using Mann-Whitney U test and chi-square test. A regression analysis was conducted to identify predictors of complications. Results: Of 218 individuals analyzed, 18 (8.4%) had postoperative complications. The most common complications were seroma (5.1%) and wound dehiscence (1.4%). The between-group analysis showed no significant differences in complication rate, whereas the operative time was significantly higher in the drainage group (P = 0.007), as well as the hospital stay (P ≤ 0.0001) and the duration of postoperative antibiotic therapy (P = 0.02). The regression analysis found body mass index and multiple basins of SLNB (axilla with groin) to be significant predictors of having a complication (P = 0.03 and P = 0.05, respectively). The operative time was found to be a predictor of seroma (P = 0.04). Conclusions: Drainage use in SLNB prolonged hospital stays and duration of postoperative antibiotic therapy, thus resulting in higher costs. The preemptive use of drainage is suggested in selected settings of patients.

The effects of breast reduction on pulmonary functions: A systematic review.

Breast reduction is one of the most commonly requested and performed plastic surgery procedures, and its psychological, esthetic, and analgesic benefits are well known. Several studies dealing with the effects of reduction mammoplasty on the physiology of respiration have been published in the past decades. This systematic review aims to assess whether bilateral breast reduction is associated with measurable improvement in lung function in women with macromastia. This review was performed in accordance with the PRISMA guidelines. PubMed, SCOPUS, and Web of Science databases were queried in search of clinical studies that investigated lung function in women undergoing breast reduction for macromastia and reported any type of parameter or outcome measure relevant to pulmonary function. The search yielded 394 articles of which 15 articles met our specific inclusion criteria. The primary outcome measures of the studies and their respective results were tabulated, contrasted, and compared. The 15 studies included in this review cover the period from 1974 to 2018. According to most included studies, reduction mammaplasty produces a change of objective respiratory parameters, such as spirometric tests or arterial blood gas (ABG) measurements; nevertheless, the clinical and functional relevance of the observed changes is debatable.

Heel reconstruction for a Marjolin's ulcer in a patient with multiple limb amputations: a case report.

Coverage of the heel defects usually represents a challenge for the proper reconstructive requirements of the weight-bearing area of the foot. The presence of multiple limb amputation may represent a further concern for conventional free flap donor sites and the patient's functional limitation, thus making reconstruction even more challenging. Amputee patients may be subjected to a higher risk of foot ulcerations and choosing the more appropriate reconstructive option in such patients is crucial. Here we describe the application of the medial plantar flap as a first-line option in a 66-year-old amputee patient with a squamous cell carcinoma arising from chronic ulceration on the left heel, that was successfully treated with limited functional limitations and excellent anatomical contour of the foot. Despite its use has been widely described for heel reconstruction, we believe that medial plantar flap would deserve greater relevance in the reconstructive scenario in such challenging cases.

A Shakespearean Dilemma in Breast Augmentation: to Use Drains or not? a Systematic Review : Drains in Breast Augmentation.

BACKGROUND: Breast augmentation is one of the most commonly requested and performed plastic surgery procedures. In order to prevent early postoperative complications such as seroma or hematoma, surgical drains could be useful. The aim is to perform a systematic review of the literature on the use of surgical drains in primary breast augmentation. METHODS: This review was performed following the PRISMA guidelines. PubMed, SCOPUS, Web of Science and Cochrane Library databases were queried in search of clinical studies describing the use of surgical drains in women undergoing primary breast augmentation with implants and documenting seroma and/or hematoma formation rate and/or infection rate. RESULTS: Initial search identified 2596 studies, and 162 were found relevant. Full-text review and application of our inclusion criteria to all retrieved papers produced 38 articles that met inclusion criteria. Among the included studies, 16 papers reported the use of surgical drains in breast augmentation, while in the remaining 22 articles drains were not used. Only 5 studies specifically investigated the role and effectiveness of surgical drains in augmentation mammaplasty and its possible relationship with complication rate such as seroma, hematoma or infection. CONCLUSIONS: Despite similar complication rates emerged from the analyzed articles, because of the heterogeneity of the studies, we were not able to demonstrate specifically whether drain use affects the rate of early postoperative complications such as seroma, hematoma and infection. Additional randomized controlled trials are strongly advocated in order to provide the necessary scientific evidence. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Peculiar Case of Large and "Unresectable" Primary Localized Cutaneous Nodular Amyloidosis of the Ankle.

Nodular cutaneous amyloidosis represents the rarest variant of primary localized cutaneous amyloidosis. The proposed management ranges from topical or systemic agents to surgical treatment. Complete surgical excision is advisable due to its potential progression to systemic amyloidosis due to dermis and subcutaneous tissue infiltration. However, in particular locations, the risk of functional complications is high, so an alternative treatment option should be considered. We report a case of a large primary nodular cutaneous amyloidosis of the leg involving the joint capsule which was successfully treated by incomplete surgical removal, without recurrences at 7-year follow-up.

The "Arrow Flap" Technique in Reduction Mammaplasty: Combining Short Scars, Narrow Base, and High and Persistent Breast Projection.

INTRODUCTION: Breast reduction is one of the most common procedures performed by plastic surgeons worldwide. Despite that several techniques have been proposed for management of ptotic or hypertrophic breasts, most of them often deal with too large breast bases, poor breast projection, persistent "dog ears," and a certain percentage of bottoming out. Lower-pole shaping of the breast remains one of the challenge of vertical mammoplasty. MATERIALS AND METHODS: The authors report their 5-year-long experience with a modification of the vertical scar technique, the "arrow flap," in which they harvest a double lateral glandular and cutaneous flap, to tighten and better shape the base of the breast and to improve the breast projection with a "double-bra" effect. From April 2015 to February 2019, 75 patients with moderate to severe macromastia/breast ptosis underwent bilateral reduction mammoplasty. RESULTS: Postoperative outcomes showed an overall satisfactory results and low incidence of complications. Two patients presented with an asymmetry between the 2 breasts, and no nipple-areola complex necrosis occurred. One patient reported a wider vertical scar, whereas no bottoming out was observed. CONCLUSIONS: All patients reported a stable and durable projection of the breast, with pleasant cosmetic results. By combining short scars and narrow base, we can obtain a pleasant lower pole reshaping of the breast, even in that challenging cases of large and squared breast. The authors believe that this technique provides a useful surgical option, increasing the versatility of the superior pedicle vertical mammaplasty both for mastopexy and breast reduction, even in cases of severe macromastia.

Use of porcine acellular dermal matrix to repair lung Hernia after minithoracotomy: A case report with 6-Year follow-up.

Lung hernia following minimally invasive cardiac surgery is rare with few reported cases in the literature. Surgical repair is debated, and several methods have been described including a variety of synthetic and biological materials. We report a case of a 36-year-old woman who developed lung hernia and a strong retraction of the pectoralis major muscle after minithoracotomy that was performed for mitral valve surgery. The herniated lung was reduced and the chest wall defect was repaired with a non-cross linked acellular dermal matrix (ADM) anchored to the thoracic wall. At a 6-year follow-up, she was asymptomatic and without recurrence of the hernia. Our experience suggests that ADMs are a safe and reliable surgical technique for lung hernia repair due to their biological and mechanical properties, even in those secondary hernias to minithoracotomy where a complete muscle coverage of the matrix could not be provided.

Reconstruction of Full-thickness Soft Tissue Defects with Integra: Risk Factors and Treatment Algorithm.

BACKGROUND: Despite the fact that dermal substitutes are widely used in reconstructive surgery, there have been no studies focused on predictors of complications or delayed matrix take. We propose an algorithm for management of soft tissue reconstruction with Integra dermal matrix, based on our 5-year-long clinical experience. METHODS: An estimated 111 patients who underwent Integra reconstruction of full-thickness soft tissue defects of different anatomical sites and etiology were enrolled, and dichotomized in two groups according to complications. Participants were further studied according to the wound healing strategy: healing by secondary intention, skin graft (STSG), and flap surgery. A regression analysis was conducted in the whole sample to identify possible predictors of complications. RESULTS: No significant differences according to complications were observed. The between-group statistical analysis showed significant differences in age, comorbidities, defect area, diagnosis, and defect site. The regression analysis revealed that the timing of split-thickness skin graft (STSG) was not influenced by age, comorbidities, body mass index (BMI), defect area, site, wound etiology, and risk factors in the subjects who underwent a two-step reconstruction. Healing by secondary intention is recommended for small post-oncological defects of the head, especially in elderly and multimorbid patients. Variables that may interfere with dermal substitutes' incorporation are independent of the timing of STSG placement; therefore, no predictors of complications or delayed matrix take were identified. CONCLUSIONS: Our findings showed that Integra can be used in a wide range of patients regardless of their general features, thus acting as a useful alternative to conventional reconstructive techniques in selected cases.

A case report of metastatic giant sarcomatoid melanoma with BRAF V600E mutation: a complete response to targeted therapy.

Sarcomatoid melanoma is an extremely rare pattern of malignant melanoma, and only few cases have been described throughout the literature. We herein report a case of a patient with newly diagnosed, metastatic giant sarcomatoid melanoma of the arm. The patient underwent surgical removal of the huge mass, and NGS sequencing demonstrated BRAF V600E mutation. In view of histological, immunohistochemical and molecular findings, a combined BRAF/MEK inhibitor (BRAF/MEK-i) therapy was prescribed as first line treatment. A complete response (over one year) to targeted therapy was obtained, and no adverse events have been reported. The patient maintained a full range of shoulder and elbow movements, and she is able to live independently and resume her daily activities. We therefore recommend that all patients with undifferentiated melanomas, sarcomatoid cutaneous malignancies or other mesenchymal tumours, should undergo BRAFV600E mutation testing.

Versatility of the O-Z flap for back reconstruction after giant basal cell carcinoma resection: A case report and review of the literature.

INTRODUCTION: Giant basal cell carcinomas are rare and potentially aggressive skin malignancies that are infrequently reported in the Literature, and they usually require aggressive surgical resection and immediate soft tissue reconstruction with skin grafts or flaps. The large size of GBCCs has relevant implications not only for the metastatic potential, but even for the reconstructive challenging due to the possible limited availability of tissues for flap coverage. PRESENTATION OF CASE: We report the peculiar case of an old patient who underwent to GBCC resection of the back measuring 16 × 13 cm, and immediate reconstruction with a large O to Z flap harvested from the back; one-year follow-up examination revealed a satisfactory result and no recurrence of the disease was observed. DISCUSSION: The review of the Literature showed that reconstructive options are mainly determined by the site and extent of the defect, exposed structures and patient characteristics and comorbidities, and previous series reported the use of skin grafts only, pedicled myocutaneous or perforator flaps, exclusively free flaps and a combination of techniques. Therefore, in this scenario local flaps such as O-Z flaps are less invasive procedures, that usually have lower rate of postoperative complications and shorter hospitalization compared to more complex procedures. CONCLUSIONS: Despite the use of O-Z flap is quite unusual for back reconstruction, we believe that this flap represents a valid and safe alternative in selected cases, particularly in the elderly and medically compromised patients with multiple comorbidities.

Acellular dermal matrix for rhinophyma: Is it worth it? A new case report and review of literature.

INTRODUCTION: nasal reconstruction after rhinophyma surgery could be challenging. In the last decade, some authors proposed the use of dermal substitutes, but only few case reports have been described throughout the Literature. PRESENTATION OF CASE: we described a new case of severe and disfiguring rhinophyma treated by total excision and a two-step reconstruction by using acellular dermal matrix and subsequent full-thickness skin graft. Despite an overall improvement of the nasal shape and a good functional recovery were observed after 12 months of follow-up, the aesthetic outcome was not satisfactory and the patient required further surgical revisions. DISCUSSION: the use of ADMs in rhinophyma poses some important aspects to be discussed. The resorption rate of the matrix and retraction rate of the skin graft make the final thickness of the neodermis unpredictable. Moreover the location of phymatous lesions and the extent of the surgical removal may strongly impact the final aesthetic outcome, often leading to a multistep procedure and patient dissatisfaction. CONCLUSION: although we believe that ADM represents a simple and reliable alternative for surgical reconstruction after rhinophyma, basing on our clinical experience we suggested some important tips and tricks in order to avoid surgical revisions, and both surgeons and patients should be aware about the potential drawbacks of this technique.

Breast Implant Texturization Does Not Affect the Crosstalk Between MSC and ALCL Cells.

In the last decade, there has been a growing interest about the possible association between anaplastic large cell lymphoma (ALCL) and breast implants (BIA-ALCL). Many variables, such as breast implants texturization, have been investigated. Breast implants often lead to the formation of a periprosthetic capsule, characterized by inflammation. The presence of the inflamed capsule has been found in the majority of patients with BIA-ALCL. Inflammation may be sustained or counteracted by mesenchymal stem cells (MSCs) by the secretion of pro- or anti-inflammatory cytokines. MSCs were isolated from three capsules surrounding micro-textured (micro-MSCs) and from three capsules surrounding macro-textured (macro-MSCs) implants; after characterization, MSCs were co-cultured with KI-JK cells (a cell line derived from the cutaneous form of ALCL). The secretion of cytokines related to inflammation, the proliferation rate, and the expression of genes referred to pro-tumoral mechanisms were evaluated. Co-cultures of KI-JK cells with micro- or macro-MSCs gave the same results about the secretion of cytokines (increase of IL10, G-CSF, and TGF-ß1 and decrease of IL4, IL5, IL12, IL13, IL17A, IFN-γ (p < 0.05) with respect to mock sample), expression of selected genes (increase for ACVR1, VEGF, TGF-ßR2, CXCL12, and MKi67 (p < 0.05) with respect to control sample), and the proliferation rate (no variation between mock and co-cultured samples). Our results suggest that MSCs derived from capsules surrounding micro- and macro-textured implants display the same effects on the ALCL cells.

Prefabricated Cervical Skin Flaps for Hemi-Facial Resurfacing: Elucidating the Natural History of Postoperative Edema Using Indocyanine Green.

BACKGROUND: The increases in capillary wall permeability and capillary hydrostatic pressure are considered to be the causes for the acute swelling seen in flaps; however, disruption of the circulating flap lymphatics could be another contributory factor. In this study we monitor the development of flap edema in a series of 18 prefabricated flaps and aim to delineate the natural history of this phenomenon by use of lymphography. METHODS: Postoperative swelling was monitored in a series of 18 pre-expanded prefabricated cervical skin flaps used for hemi-facial burns-scar resurfacing. Time to spontaneous resolution, presence or absence of venous congestion, and clinical outcome were recorded. In two cases, indocyanine-green (ICG) lymphography was used to monitor the dermal backflow pattern until swelling had completely resolved. Average moving velocity of ICG after injection as well as flap thickness was also recorded over the follow-up period. RESULTS: The average moving velocity of ICG in the flap lymphatics improved from 0.48 cm/min to 1.5 cm/min in the first 12 days after flap transfer. The dermal backflow pattern was stardust in the first 12 days, indicating moderate lymphedema, transforming to splash from week three, and a robust collecting lymphatic vessel occurring from the fifth month, indicating mild lymphedema and lymphatic channel recovery, respectively. CONCLUSION: Transient swelling was observed in all prefabricated flaps in our series. We postulate that this is mostly secondary to lymphatic disruption that subsides as lymphangiogenesis takes place. ICG lymphography is an inexpensive, safe, and easy-to-use imaging technology that could be used in the monitoring of postoperative lymphedema seen in prefabricated flaps.

Acellular Dermal Matrices and Paraffinoma: A Modern Tool for a Nearly Obsolete Disease.

Paraffinoma is a destructive complication of paraffin oil injection, usually associated with massive tissue destruction, thus requiring radical surgery and subsequent complex reconstruction. Although breast and penile paraffinomas have been widely described and their management is quite standardized, paraffinomas of the knee are still rare and only few case reports or small case series are available in the current literature. We describe the case of a 77-year-old man with a large paraffinoma of the right knee that occurred after self-injection of paraffin oil, 58 years before. He underwent wide surgical resection of the soft tissues overlying the knee and subsequent two-stage reconstruction by using acellular dermal matrix and, after 20 days, split-thickness skin grafts. Follow-up after 16 months showed no signs of skin ulcerations or inflammation, with an overall improvement in function. Even though conventional flap reconstructions may be still useful, the authors believe that acellular dermal matrices represent a safe, reliable, and less invasive alternative for challenging soft tissue reconstructions even in elderly patients with multiple medical problems.